Would it be reasonable to begin considering GLP1 RAs or finerenone for patients with heart failure with recovered LVEF in light of recent trials such as SELECT and FINEARTS-HF showing some success in HFpEF and HFmrEF populations?
For patients with heart failure with recovered ejection fraction (HFimpEF), would you consider starting GLP1 RAs or finerenone based on recent trials like SELECT and FINEARTS-HF?
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I reject the premise of the question. Patients with HFrEF who improve on medical therapy do not become HFpEF. The pathophysiology of these diseases are entirely distinct and it speaks to the limitation of EF as a categorical variable. HFrEF patients have cardiomyopathy that manifests over time as dilatation of the left ventricle. On medications there is a potential for positive remodelling such that two things occur:
- The ventricle is no longer dilated (or less dilated).
- The heart failure syndrome improves. That is, they usually no longer require diuretics and at worst will experience NYHA Class II symptoms.
- The patient remains at risk for recrudescence of their cardiomyopathy. The disease does not go away. The EF may slide with time and the symptoms may come back.
In other words, if you never met them before and didn't know what meds they were on, you'd be hard pressed to say they have heart failure at all.
So with respect to finerenone, I would not switch them off the spironolactone that made them better unless you can show me data that it's a superior agent in HFrEF/cardiomyopathy patients.
With respect to GLP-1, if the patient wanted to lose weight on that agent I would be ok with them giving it a shot, but I remain cautious regarding the potential risk of more hospitalizations in this group: Neves et al., PMID 37028749.
The results of studies such as FINE-ARTS-HF lend promise to a space for patients with HFpEF. SELECT enrolled more of a general cardiovascular risk-enhanced population. The challenge in patients with "HFimpEF" - those that have recovered EF, is that it is difficult to understand in which category they fall along the spectrum of HF - in other words - are they more like HFpEF or HFrEF. Either way, in carefully selected patients, I think many of these therapies are reasonable to trial assuming no contraindications.